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43 Cards in this Set

  • Front
  • Back
Tension Pneumothorax
-Life-threatening as increased intrapleural and intrathoracic pressures cause compression of heart and great vessels
-Cardiovascular collapse
-Emergent treatment with needle thoracostomy
-Chest tube inserted after needle decompression
Hemothorax and Open Pneumothorax
-Blood (hemo) or air (pneumo) in pleural space
-Chest tube insertion needed
-Cautious application of dressing to open (sucking) chest wound; tension pnuemothorax can result
• Allow small amt of air to escape from occlusive dressing
Cardiac Tamponade
-3 signs: muffled sound, increased pulse pressure, distended jugular vein
-Bleeding into pericardial space
-Impairs pumping ability of heart
-May be difficult to diagnose; suspect in patient with symptoms of decreased CO who doesn’t respond to treatment
-Treated by pericardiocentesis
Pulmonary Contusion
-Bruising of lung tissue
-Often results in pneumonia and ARDS
-May require long-term ventilatory support
Rib Fractures
-Seriousness varies; treatment also varies
-May result in flail chest:
• Paradoxical respirations result
• Tx: intubation, ventilation, pain mgmt
Aortic Disruption
-Life-threatening injury requiring emergency surgical intervention
-Symptoms include weak pulses, pain, and hoarseness
-Chest x-ray shows widened mediastinum
-Confirmed by aortogram
Compartment Syndrome
-Severe pain is first symptom
-May need compartmental pressure monitoring
-Treated with fasciotomy
-Slice skin lengthwise to allow for expansion if swelling
-Don’t close incision, just dressing until bowel heals, then close
Fat Embolism
-Suspect with long-bone, pelvic, and multiple fractures
-Symptoms include fever, tachycardia, and new onset of respiratory distress
-Treated with O2, intubation, ventilation, and PEEP
Scalp Lacerations
-Break in scalp; risk for infections
-Scalp is very vascular
-When might these lacerations be dangerous?
-Transient loss of counsciousness
Cerebral Contusion
-Bruising of the brain
-S&S and severity vary, depending on location of injury
Penetrating Injury
-Knife, gunshot, ice picks, nail guns, etc.
-S&S vary according to location and extent of injury
-What are the problems associated? (infection, several structures affected-vessels, tissue, brain function)
Epidural Hematoma
-Blood clot between dura and skull; frequently in temporal area
-Laceration of middle meningeal artery or veins-Develops rapidly, in minutes to hours (usually within first 24-48 hrs)
Epidural S&S
-Lucid interval often precedes neurologic decline
-Early signs: headache, irritability, restlessness
-Typical later signs: from brainstem compression:
• Ipsilateral dilated pupil (same side of injury)
• Contralateral hemiparesis (opposite)
• Decerebration (away from)
• Progressive unconsciousness
Management of Epidural Hematoma
-Surgical evacuation through burr hole and drain
-Surgery MUST be performed early
Subdural Hematoma
-Clot within subdural space; may be bilateral
-Usually from torn cortical vein
-May be multiple and associated with contusions
Onset of Subdural Hematoma
-Acute: develops rapidly with minutes to 48 hours
-Subacute: occurs 2 days to 2 weeks after injury
-Chronic: occurs weeks to months after injury
Signs of Subdural Hematoma
-Acute: S&S are often the same as epidural hematoma
-Lucid interval often precedes neurologic decline
-Early signs: headache, irritability, restlessness
-Progressive unconsciousness
Management of Subdural Hematoma
-Surgical evacuation through burr hole
-Acute: Surgery MUST be done early; includes excision of hematoma, resection of contused brain, and draining
Intracerebral Hematoma
-Clot deep within the brain tissue
-May occur from trauma, ruptured aneurysm, vascular tumor, or ruptured vessels from hypertension
-Varied S&S
-Small ones may resolve
-Large ones may require surgical excision
Pathophysiology of ICP
-Normal ICP ranges from 0-15mmHg
• May fluctuate in response to BP changes, respiratory cycle, coughing, and Valsalva maneuvers
-IICP (16mmHg or greater) is life threatening
-Cranial vault contains 3 noncompressible contents
• Semi-solid brain, intravascular blood, and CSF
• If volume of one increases, one or two of the other two must decrease proportionately
• If not, ICP increases
-CSF is displaced into the spinal canal or absorbed into the venous system
-When compensation fails, additional intracranial volume is not tolerated and ICP increases
-Increased volume leads to decreased compliance, which leads to decreased cerebral blood flow, which leads to tissue hypoxia, which leads to cerebral edema, which causes IICP and the cycle starts over
Intraventricular Disadvantages
-Increased risk of infection
-Increased risk of neurological deficit
-Catheter may be difficult to place if ventricles are small
-Frequent calibration needed to ensure accuracy
Nursing Care: ICP Monitoring
-Maintain closed system
-Monitor for infection
-Change dry sterile gauze according to protocol
-Level with ventricles
-Zero and calibrate frequently
-Record iCP and CPP (ex. Every hour)
-Report any changes to the Physician
-Early clinical changes:
• Changes in arousal and mental status, increased muscle tone, motor weakness, respiratory pattern changes (yawning, deep sighs, rate changes), small reactive pupils, bilateral Babinski’s reflexes
-Late clinical changes:
• Decorticate posturing and Cheyne-Stokes respirations
Nursing Assessment GCS
-Rapid standardized tool consisting of eye opening, verbal response, and motor response
• Best response, trend more meaningful than actual numbers, report specific abnormalities
Nursing Assessment GCS
-Rapid standardized tool consisting of eye opening, verbal response, and motor response
∑ Best response, trend more meaningful than actual numbers, report specific abnormalities
∑ High number (approaching 15) means normal functioning
Low number (approaching 3) indicates impaired functioning
Motor Status
-Assess spontaneous movement of all extremities, muscle strength (push-pull resistance), muscle tone, coordination, and abnormal posture and reflexes
-Assess for symmetry
-Decorticate (abnormal flexion): towards spinal cord
-Decerbrate (abnormal extension): away from spinal cord
Babinski’s Reflex
-Normal reflex is flexion
-Dorsiflexion of big toe with fanning of the other toes
-Indicates upper motor neuron disease
Neurological Assessment
-Mental status
-Vital signs
-Cranial nerve functioning
-Motor status
Mental Status
-Arousal (consciousness): response to the environment
∑ Assess orientation to person, place, and time AFTER consciousness is established
-Language skills: speaking and following verbal commands
-Memory: short and long term memory
∑ Continuous vs. PRN
-Level is very important
-Transfer pack: plastic bag used to transport blood is sterile and sometimes used
Nursing Interventions: IICP
-Important to control environment and activities to minimize stimulation that contributes to IICP
-Prevent complications from immobility
Medical Interventions: IICP
-Reduce ICP
-Maintain the airway
-Maintain cerebral perfusion
-Prevent secondary head injury
-Avoid nutritional deficits
-Reduce the incidence of infection
Surgical Interventions: IICP
-Evacuation of hematomas
-Placing ICP monitors
-Remove bony fragments if necessary
-Repair lacerations
-Exploration and repair of brain injuries
Spinal Cord Injury
-Cervical spine X-rays and possible CT studies
-Reduction with cervical or halo traction
-Emergency administration of methylprednisolone (IV to reduce swelling)
-Assess for distributive (spinal) shock
∑ May need vasopressors
-Need complete neurological exam
∑ Frequent assessment and documentation of motor & sensory status of all extremities
-Postural reduction or surgical fusion
Priority Assessments of SCI
-Airway and ventilation
-Paralysis of diaphragm & intercostals muscles will result in ineffective breathing patterns
∑ C1-C3: ventilator dependent
∑ C4-C5: may or may not need ventilator
∑ Below C5: have intact diaphragmatic breathing
Assessment of SCI
-Entire body: motor/sensory
-Spinal shock
-Sensory/motor loss
-Autonomic dysfunction
-Bowel/bladder dysfunction
Spinal Shock
-Common with complete lesions
-Decreased venous return
-Venous stasis
Emergency Management of SCI
-Stabilization: tongs, surgery, halo
-Corticosteroid protocol
-Kinetic bed: to prevent secretions, moves pt side to side to use respiratory muscles and not develop pneumonia
Nursing Care: SCI
-Potential for ineffective airway clearance
-Potential for decreased CO r/t spinal shock
-Improve venous return (vasopressors)
-Long-term rehab needs
Autonomic Dysreflexia
-Occurs T6 or above after resolution of spinal shock
-Intense sympathetic response to stimuli
∑ Kinked catheter
∑ Impaction
-Severe hypertension, headache, and bradycardia
-Assess and remove the cause
-Trauma pt’s are at high risk for developing infection
∑ Nosocomial infections are a major source of infection
∑ Especially worry about pulmonary infection & catheter sepsis (increases if catheters are in place over 1 week)
-Management focuses on eradicating the invading bacteria & increasing the pt’s resistance to infection
Clinical Signs of Infection
-Decreased urine output (hallmark sign)
-U/A: specific gravity, protein, myoglobin, red or white blood cells
-Serum creatinine, BUN, creatinine clearance (direct reflection of glomerular filtration)